Mental Health: Targeted School-Based Cognitive Behavioral Therapy Programs to Reduce Depression and Anxiety Symptoms

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to mental health:

Werner-Seidler A, Perry Y, Calear AI, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis. Clinical Psychology Review 2017;51;30-47.

The systematic review included 81 studies (search period through 2015). The team examined CBT programs for targeted school-based programs (29 studies) and universal school-based programs (38 studies) separately. Ten studies from the published review were excluded because they either did not evaluate CBT programs or they did not provide data for analysis.

The team examined a subset of 11 targeted studies from the United States and abstracted supplemental information about study, intervention, and population characteristics; and performed data analysis. Data from the subset were compared with the overall body of evidence.

The CPSTF finding is based on results from the published review, additional information from the subset of studies, and expert input from team members and the CPSTF.

Anxiety and depression are common among children and adolescents, and they can persist into adulthood, increasing risks for suicide, risk-taking behavior (e.g., substance abuse, sexual experimentation), teenage pregnancy, conduct disorder, delinquency, and poor academic outcomes (Anxiety and Depression Association of America, 2018; Weller et al., 2000; Werner-Sielder et al., 2017).

Schools can play an important role in preventing and reducing anxiety and depression. Cognitive behavioral therapy (CBT), the most commonly used therapy for anxiety and depression, helps children and adolescents change negative thoughts into more positive, effective behaviors.

Implementing CBT programs in schools supports several components of the Whole School, Whole Community, Whole Child (WSCC) Model focused on promoting students’ health (CDC, 2018).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 29 studies of targeted school-based CBT.

• Small decreases were reported for symptoms of depression (21 studies) and anxiety (14 studies).
• Interventions delivered by external mental health professionals showed larger effects than those delivered by trained school staff.

A systematic review of economic evidence has not been conducted.

The CPSTF finding should be applicable to school aged children (aged 7-18 years) in the United States.

Additional research and evaluation are needed to answer the following questions and fill existing gaps in the evidence base. (What are evidence gaps?)

Evidence gaps identified in systematic review.

• How can advances in technology be used to improve intervention reach and availability at a population level?
• How do program results differ when asymptomatic youth participate?
• What effect does parental involvement have on outcomes? Which strategies work best to incentivize and engage parents or caregivers?
• What are the infrastructure and personnel needs required to sustain programs?

The CPSTF further identified the following evidence gaps as areas for future research:

• Which strategies best balance the need for parental awareness with child confidentiality?
• What are the long-term effects of early interventions to reduce anxiety and depression symptoms?
• Are programs as effective if implemented in private schools?
• What are the follow-up approaches that best support the maintenance of program effects over time?

• Depression symptoms were most frequently measured with the Children’s Depression Inventory, followed by the Beck Depression Inventory, and the Kiddie-Schedule for Affective Disorders and Schizophrenia.
• Anxiety symptoms were most frequently measured with the Spence Children’s Anxiety Scale, followed by the Revised Children’s Manifest Anxiety Scale.
• The included studies from the United States targeted adolescents (10-17 years), and were delivered by external mental health professionals (8 studies) or trained school staff (3 studies). Study populations represented a range of racial and ethnic groups.

Effectiveness Review

• Analytic Framework [PDF – 478 kB]

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Werner-Seidler A, Perry Y, Calear AI, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis. Clinical Psychology Review 2017;51;30-47.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Arnarson EO, Craighead WE. Prevention of depression among Icelandic adolescents. Behaviour Research and Therapy 2009;47:577 85.

Balle M, Tortella-Feliu M. Efficacy of a brief school-based program for selective prevention of childhood anxiety. Anxiety, Stress, and Coping 2010;23(1):71 85.

Castellanos N, Conrod P. Brief interventions targeting personality risk factors for adolescent substance misuse reduce depression, panic and risk-taking behaviours. Journal of Mental Health 2006;15:645 58.

Clarke GN, Hawkins W, Murphy M, Sheeber LB, Lewinsohn PM, et al. Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: a randomized trial of group cognitive intervention. Journal of the American Academy of Child and Adolescent Psychiatry 1995;34:312 21.

Cooley-Strickland MR, Griffin RS, Darney D, Otte K, Ko J. Urban African American youth exposed to community violence: A school-based anxiety preventive intervention efficacy study. Journal of Prevention & Intervention in the Community 2011;39:149 66.

Dadds MR, Spence SH, Holland DE, Barrett PM, Laurens KR. Prevention and early intervention for anxiety disorders: A controlled trial. Journal of Consulting and Clinical Psychology 1997;65:627 35.

Gillham JE, Reivich KJ, Brunwasser SM, Freres DR, Chajon ND, et al. Evaluation of a group cognitive-behavioral depression prevention program for young adolescents: a randomized effectiveness trial. Journal of Clinical Child and Adolescent Psychology 2012;41:621 39.

Jordans MJ, Komproe IH, Tol WA, Kohrt BA, Luitel NP, et al. Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial. Journal of Child Psychology and Psychiatry 2010;51:818 26.

Kindt KC, Kleinjan M, Janssens JM, Scholte RH. Evaluation of a school-based; depression prevention program among adolescents from low-income areas: a randomized controlled effectiveness trial. International Journal of Environmental Research and Public Health 2014;11:5273 93.

Kiselica MS, Baker SB, Thomas RN, Reedy S. Effects of stress inoculation training on anxiety, stress, and academic performance among adolescents. Journal of Counseling Psychology 1994;41:335 42.

Manassis K, Wilansky-Traynor P, Farzan N, Kleiman V, Parker K, et al. The feelings club: randomized controlled evaluation of school-based CBT for anxious or depressive symptoms. Depression and Anxiety 2010;27:945 52.

McCarty CA, Violette HD, McCauley E. Feasibility of the positive thoughts and actions prevention program for middle schoolers at risk for depression. Depression Research and Treatment 2011;241386.

McCarty CA, Violette HD, Duong MT, Cruz RA, McCauley E. A randomized trial of the positive thoughts and action program for depression among early adolescents. Journal of Clinical Child and Adolescent Psychology 2013;42:554 63.

McLoone JK, Rapee RM. Comparison of an anxiety management program for children implemented at home and school: lessons learned. School Mental Health 2012;4:231 42.

Mifsud C, Rapee RM. Early intervention for childhood anxiety in a school setting: outcomes for an economically disadvantaged population. Journal of the American Academy of Child and Adolescent Psychiatry 2005;44:996 1004.

Miller LD, Laye-Gindhu A, Liu Y, March JS, Thordarson DS, Garland EJ. Evaluation of a preventive intervention for child anxiety in two randomized attention-control school trials. Behaviour Research and Therapy 2011;49:315 23.

Nobel R, Manassis K, Wilansky-Traynor P. The role of perfectionism in relation to an intervention to reduce anxious and depressive symptoms in children. Journal of Rational-Emotive and Cognitive-Behavior Therapy 2012;30:77 90.

Pedro-Carroll JL, Cowen EL. The children of divorce intervention program: an investigation of the efficacy of a school-based prevention program. Journal of Consulting and Clinical Psychology 1985;53:603 11.

Puskar K, Sereika S, Tusaie-Mumford K. Effect of the Teaching Kids to Cope (TKC) program on outcomes of depression and coping among rural adolescents. Journal of Child and Adolescent Psychiatric Nursing 2003;16:71 80.

Roberts C, Kane R, Thomson H, Bishop B, Hart B. The prevention of depressive symptoms in rural school children: A randomized controlled trial. Journal of Consulting and Clinical Psychology 2003;71:622 8.

Rohde P, Stice E, Shaw H, Gau JM. Cognitive-behavioral group depression prevention compared to bibliotherapy and brochure control: nonsignificant effects in pilot effectiveness trial with college students. Behaviour Research and Therapy 2014;55:48 53.

Sheffield JK, Spence SH, Rapee RM, Kowalenko N, Wignall A, et al. Evaluation of universal, indicated, and combined cognitive-behavioral approaches to the prevention of depression among adolescents. Journal of Consulting and Clinical Psychology 2006;74:66 79.

Siu AF. Using FRIENDS to combat internalizing problems among primary school children in Hong Kong. Journal of Evidence-Based Psychotherapies 2007;7:11 26.

Stallard P, Sayal K, Phillips R, Taylor JA, Spears M, et al. Classroom based cognitive behavioural therapy in reducing symptoms of depression in high risk adolescents: pragmatic cluster randomised controlled trial. British Medical Journal 2012;345:e6058.

Stice E, Burton E, Bearman SK, Rohde P. Randomized trial of a brief depression prevention program: An elusive search for a psychosocial placebo control condition. Behaviour Research and Therapy 2007;45: 863 76.

Stice E, Rohde P, Seeley JR, Gau JM. Brief cognitive-behavioral depression prevention program for high-risk adolescents outperforms two alternative interventions: a randomized efficacy trial. Journal of Consulting and Clinical Psychology 2008;76:595 606.

Wijnhoven LA, Creemers DH, Vermulst AA, Scholte RH, Engels RC. Randomized controlled trial testing the effectiveness of a depression prevention program (‘Op Volle Kracht’) among adolescent girls with elevated depressive symptoms. Journal of Abnormal Child Psychology 2014;42:217 28.

Woods B, Jose PE. Effectiveness of a school-based indicated early intervention program for Maori and Pacific adolescents. Journal of Pacific Rim Psychology 2011;5:40 50.

Yu DL, Seligman ME. Preventing depressive symptoms in Chinese children. Prevention and Treatment 2002;5:article 9.

Refer to the existing systematic review for information about the search strategy:

Werner-Seidler A, Perry Y, Calear AI, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis. Clinical Psychology Review 2017;51;30-47.

Anxiety and Depression Association of America. Facts and Statistics. Silver Spring (MD): 2018. [Cited 10/1/18]. Available from URL: https://adaa.org/about-adaa/press-room/facts-statistics.

Weller EB, Weller RA. Depression in adolescents growing pains or true morbidity? [Review][20 refs]. Journal of Affective Disorders 2000;61:Suppl-13.

Werner-Seidler A, Perry Y, Calear AI, Newby JM, Christensen H. School-based depression and anxiety prevention programs for young people: a systematic review and meta-analysis. Clinical Psychology Review 2017;51;30-47.

Centers for Disease Control and Prevention. Whole School, Whole Community, Whole Child (WSCC). Atlanta (GA): 2018. [Cited 1/30/19]. Available from URL: https://www.cdc.gov/healthyschools/wscc/index.htm.

The following considerations for implementation are drawn from studies included in the existing evidence review, the broader literature, and expert opinion.

• Confidentiality of student information should be a priority, and policies should be clearly communicated to parents and students, especially when there will be group sessions.
  • Programs should provide students with information about the group process, general risks associated with participation (e.g., privacy, confidentiality concerns or limitations), and rules for participation.
• Parents should be notified when students participate in programs or receive mental health services (though this must be balanced with student confidentiality).
• Students should have access to additional mental health services in case issues arise (either on-site or by referral).
• Referral processes should be in place and consistently followed by staff who detect possible child maltreatment or risk of harm to self or others.
• Schools should decide whether trained school personnel or external mental health professionals will deliver program components.
  • School staff may be familiar with the student population and school environment, and there may be greater opportunities for program sustainability. They may not, however, have mental health training that would prepare them to handle additional issues.
  • External mental health professionals are professionally trained for mental health issues, but they may not be as familiar with individual students, and additional funding may be required.
• Schools should decide whether universal CBT programs, targeted CBT programs for at-risk individuals, or both, are best suited for their student population. Some schools may prefer a stepped approach to deliver universal CBT programs first followed by targeted CBT programs for at-risk, symptomatic individuals who do not respond to the universal program. Other schools may prefer to deliver one program only.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of children and adolescents who get appropriate treatment for anxiety or depression — EMC‑D04
• Increase the proportion of children and adolescents who get preventive mental health care in school — EMC‑D06